Norfolk Island Ditching ATSB Report - ?

Slats you and I are in furious agreement. It goes a long way back, Young, Seaview, Lockhart River. Why the accident at Lockhart River didn't shake the tree goes to the heart of your post, we should all be concerned. Twice as many people killed as Seaview and all we get is a Coronial Inquiry. It has been stated many times that the only real change is when our TV screens are filled with images such as those of Air Asia, but with the Opera House as a backdrop.

INDEPENDENT senator Nick Xenophon has called large political donations by listed regional airline Rex “incredibly baffling” and said he would be buying shares in the company so he could press board members on why the donations were made.

Mr Xenophon, who led a Senate committee inquiry into much criticised government investigation into the crash of a Rex-owned passenger plane off Norfolk Island, said the airline had an “obligation” to disclose why the donations were made.

Between July and November 2012 — amid a three-year inquiry into the Norfolk Island crash — Rex made a $250,000 donation to the ALP, $95,700 to the federal Nationals and $40,000 to the Liberal Party. This made the small airline one of the biggest political donors in the country.

“Rex is a public company and it had an obligation to explain whether even one (word) regarding the crash was spoken with any of the political parties,” Mr Xenophon told The Australian.

“This largesse to political parties is inexplicably baffling and I will be buying some shares in Rex and asking them to explain it.”

Rex spokeswoman Alicia Chapple has declined to respond to repeated questions from The Australian this week regarding the donations and other matters, saying that the airline did “not see the need to devote additional resources to this matter”.

The airline had earlier incorrectly claimed it had made no donations to the LNP; however, when shown otherwise, Ms Chapple said the airline had meant it had made no donations to the Queensland LNP.

Of particular interest was Rex’s $250,000 donation to the federal ALP given the airline was a highly vocal critic of the Labor government.

In 2013 Rex publicly said the ALP was “hellbent” on destroying regional aviation and “along with it pretty much the rest of the economy”.

Mr Xenophon said it appeared to defy reason why Rex would donate heavily to a government it would shortly afterwards describe as “destroying its industry”.

“Perhaps Rex had a case of Stockholm syndrome?” he said.

In 2009 a Rex aeroplane — operated under the group’s Pel-Air brand — ditched into the ocean with six passengers on board, badly injuring one. A lengthy Australian Transport Safety Board investigation blamed the Pel-Air pilot involved in the crash but failed to mention 57 breaches or “serious deficiencies” at Pel-Air.

Mr Xenophon headed a Senate committee inquiry into that botched investigation, which led to the federal government last month calling on the ATSB to reopen the investigation.

Rex has also come under the spotlight after it was last year awarded a series of key Queensland government contracts which had previously been held by Cairns-based rival Skytrans.

Officials from the Australian Licensed Aircraft Engineers Association have briefed politicians from all parties on the issue and received initial support from independent senator Nick Xenophon for a disallowance motion aimed at reversing Civil Aviation Safety Authority amendments to maintenance regulations.

Senator Xenophon filed a notice of motion on December 4 for disallowance of the Civil Aviation Safety Regulations Part 145 Manual of Standards amendments relating to specialist maintenance workers.

Some interesting events in The Supreme Court last week, even reference to PPRuNe posts. Man on the scene said it didn't go all Pel-Air way. Enough concessions to give both flight nurse and doctor some optimism.

Also, reading between creampuff lines points me to certain lawyer with past history with 'firies' and credit cards. Townsville refueller's mates daughters uncle, reports someone has some sworn written dynamite to chuck around with this one too.

Senator Xenophon has not lost interest.

Finally as an observation, perhaps a rumour, and off topic but germane to the big picture, watch Truss and The nationals fit into the current media ignited beatup in Canberra. I understand Truss nor The Nationals will wear Turnbull. As a coalition it needs readdressing if there is any leadership change. The future aviation portfolio is now vague and up in the air at this time.

It remains unclear to me, despite (or perhaps because of) reading all the voluminous tomes from the multiple investigations and associated inquiries, how this was considered an Airwork flight.

It is my understanding that the medical / travel insurer who paid for the flight for the patient, did not ring Pel-Air, they rang Careflight. Careflight then CHARTERED the aircraft and crew from Pel-Air. If Pel-Air were not the provider of the air ambulance service but only the aircraft and crew, then it was a CHARTER and the Airwork provisions for alternates do not apply. Can anyone clarify this?

The classification of these kinds of operations is a pustulent regulatory sore that's been running for decades. It's one of the many inconvenient and embarrassing aspects of the NGA ditching. But I do note that it seems to me that, on any analysis, the flight nurse and doctor were crew, not passengers, and that complicates things. A lot ...

But don't worry: It will all become crystal clear with the new, simple, outcomes-based classification of operations rules in 1998.

(On the proper defendant question, I would have thought the employer, the AOC holder, the PIC and CASA would, at least, have all been named or joined as defendants.)

I always found it difficult to understand Transair being given the sword over Lockhart River when it was an Aero-Tropics flight, where pax carried Aero-Tropics Tickets, sold via Aero-Tropics Travel Agent, flown in an aircraft with Aero-Tropics written all over it, flown on Aero-Tropics RPT route. I can see why the Westwind Pel-Air Careflight matter would cause confusion.

Yes we need more regulations. Not clearer regulations. We most likely need another 'Truss Review' to take over from where the last one left off.

Seems as though Carry on is rolling out a few trolls of his own and stealing material from, how does he refer to it, ah yes the "unspeakable PPRuNe" or UPP.

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"Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air."

Good point; and, in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion.

For the record that quote from P9 is one I made on the Senate Thread. He can't have it both ways, on the one hand calling me a troll and on the other starting his blog with an unattributed quote from me. You might want to check the dictionaryagain for the meaning of the word hypocrisy TB.

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Thanks Sidebar. Just reading the review however sort of backs up what is wrong with HF, its all good theory but doesn't really provide solutions.

Quote: His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization. and then this from a reviewer at MIT:

Quote: The book is a model of organizational analysis and application of theory at multiple levels, including an ability to reveal the gaps in theory without undermining the theoretical analysis." The ATSB HF experts are all very clever and can show you what led to the end result but it doesn't offer a practical solution. As an example QF1 went into all sort of details about flap25 and carbon brakes etc but overlooked the simple fact that if the go-around was conducted according to the manual (pressing the TOGA buttons) then it probably would not have happened.

Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air.

Sarcs I know you are keen on references and accuracy. The above is at #2656 on the Senate thread.

This is part of the reponse at #2661:

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Good point Lefty and in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion.

So not only is Carry on getting his blogs from Aunty Pru slipped into PPRuNe but he is also lifting his postings from a closed thread into his blogs onto Aunty Pru and not even the complete posting! I think he has learnt a few shonky techniques from CASA on how to manipulate documents to present "new" material.

This donation look dodgy and hard to explain to the plebs, that the Rex board, on which John Sharp sits, donates $95K of shareholders money to National Party, where John Sharp is the federal treasurer. The donation to ALP looks like having a bet each way. Wonder what the shareholders have to say about this?

The PelAir Supreme Court story is a complex one and the following was written by a person who was in the Supreme Court last week.

If only they could get all their facts right. This is what is stated in the link UITA posts:

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One, on reading the original ATSB ‘Preliminary Report’ and comparing the ‘Final ATSB Report’, finds there are inconsistencies between both reports. For example the person flying and the positions of all on board is not reported, nor whom and whether the aircraft became visual is canvassed.

This is from the Preliminary report of January 2010- 2 months after the accident:

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Upon arrival at Norfolk Island, the copilot conducted a very high frequency omnidirectional radio range/distance measuring equipment (VOR/DME) instrument approach procedure6 for a landing on runway 29 (Figure 1). However, the flight crew was not ‘visual’ at the missed approach point,7,8 and a missed approach was carried out at 1004. At that time, it was dark and raining with low cloud and poor visibility.

Following the missed approach, the pilot in command assumed control of the aircraft as the handling pilot. A second instrument approach was conducted for runway 29; however, the crew were again unable to visually acquire the runway, and initiated a second missed approach at about 1013. The flight crew then repositioned to conduct a VOR/DME instrument approach for landing on runway 11. The runway 11 instrument approach procedure permitted the crew to descend 100 ft lower than the runway 29 approach before acquiring visual reference with the runway (Figure 2).

The crew did not gain visual reference with runway 11 and conducted a third missed approach at about 1019, before reporting to Norfolk Unicom that they were planning to ditch because the aircraft was running out of fuel. The crew then conducted a third instrument approach for runway 29 (four approaches in total), but again did not visually acquire the runway.

I'm not sure how much clearer it can be about who was flying when and what they saw (or didn't see)at the minima. I am guessing that the prelim facts were based largely on interviews with the crew.

This part in the prelim also casts doubt on this part in the article:

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The small group, who were now in the sea, had some inoperative life jackets and not been trained correctly by the operator [PelAir] and undertaken what is known as 20.11 training. The 20.11 trainging includes in-water escape and life jacket training and aircraft escape techniques.

This is from the prelim:

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The pilot in command and medical staff stated that their ditching training had helped them when escaping from the aircraft.

I think the prelim is worth another read by anyone interested in this story as it is the only part of the investigation that hasn't been tainted when you compare it to the final.

Amnesia can now be again added to the failings of integrity and safety focus in ATSB reports on the repeated release today of its study titled Starved and Exhausted: Fuel Management Aviation Accidents.

It leaves out the fuel management related crash investigation of the century, the one in which a Pel-Air flight was ditched near Norfolk Island in 2009.

But the notification of the study by the ATSB using Twitter is even stranger. It’s recycling the study it published according to the fly sheet in March 2013 and the web page the link to the download takes you was last edited in April 2014.

Among the illustrations in the study is the top of page photo of the retrieval of a Piper Cherokee Six that ditched while conducting inter-island charters between Mackay and the Whitsundays in April 2008.

So strange. If the ATSB can haul an entire Cherokee out of the Whitsunday waters, what really stopped it being sufficiently curious about the ditching the Pel-Air Westwind corporate jet from the water close to Norfolk Island to recover its flight data recorder?

What didn’t the ATSB want to know? Now, in 2015, we know that the ATSB and CASA variously withheld or dismissed serious findings about safety deficiencies in Pel-Air’s operations, owned by the generous Labor and Coalition political donor REX, who lavished completely unrelated and out of character gifts of money to both sides of politics in the same year that a discredited ATSB report into the crash was released.

The optics aren’t good. The ATSB re-releases a report that leaves out the most important fuel management accident in its history at the same time as it is trying to get away with conducting a new review of that Pel-Air rash report it insists is fault free.